<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group hide">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_id" data-rule="required" data-source="presentation/index" class="form-control selectpage form-control" name="row[presentation_id]" type="text" value="{$row.presentation_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Patient_name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-patient_name" class="form-control form-control" name="row[patient_name]" type="text" value="{$row.patient_name}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Gp')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-gp" class="form-control form-control" name="row[gp]" type="text" value="{$row.gp}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Sr')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-sr" class="form-control form-control" name="row[sr]" type="text" value="{$row.sr}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Hr')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-hr" class="form-control form-control" name="row[hr]" type="text" value="{$row.hr}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Investigation')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-investigation" class="form-control form-control" name="row[investigation]" type="text" value="{$row.investigation}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Birthday')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-birthday" class="form-control datetimepicker form-control" data-date-format="YYYY-MM-DD" data-use-current="true" name="row[birthday]" type="text" value="{$row.birthday}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Age_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-age_number" class="form-control form-control" name="row[age_number]" type="number" value="{$row.age_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Age_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-age_unit" class="form-control form-control" name="row[age_unit]" type="text" value="{$row.age_unit}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Age_number_baby')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-age_number_baby" class="form-control form-control" name="row[age_number_baby]" type="number" value="{$row.age_number_baby}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Age_unit_baby')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-age_unit_baby" class="form-control form-control" name="row[age_unit_baby]" type="text" value="{$row.age_unit_baby}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Age_group')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-age_group" class="form-control selectpicker" name="row[age_group]">
                {foreach name="ageGroupList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.age_group"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Body_weight')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-body_weight" class="form-control form-control" name="row[body_weight]" type="text" value="{$row.body_weight}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Height')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-height" class="form-control form-control" name="row[height]" type="text" value="{$row.height}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Sex')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-sex" class="form-control selectpicker" name="row[sex]">
                {foreach name="sexList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.sex"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Last_menstrual_period_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-last_menstrual_period_date" class="form-control datetimepicker form-control" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[last_menstrual_period_date]" type="text" value="{$row.last_menstrual_period_date}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Structured_ids')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-structured_ids" data-rule="required" data-source="structured/index" data-multiple="true" class="form-control selectpage form-control" name="row[structured_ids]" type="text" value="{$row.structured_ids}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medical_history')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-medical_history" class="form-control  form-control" rows="5" name="row[medical_history]" cols="50">{$row.medical_history}</textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Concomitant_therapies')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-concomitant_therapies" class="form-control form-control" name="row[concomitant_therapies]" type="text" value="{$row.concomitant_therapies}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Past_drug_history_ids')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-past_drug_history_ids" data-rule="required" data-source="past/drug/history/index" data-multiple="true" class="form-control selectpage form-control" name="row[past_drug_history_ids]" type="text" value="{$row.past_drug_history_ids}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Death_ids')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-death_ids" data-rule="required" data-source="death/index" data-multiple="true" class="form-control selectpage form-control" name="row[death_ids]" type="text" value="{$row.death_ids}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_info_ids')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_info_ids" data-rule="required" data-source="parent/info/index" data-multiple="true" class="form-control selectpage form-control" name="row[parent_info_ids]" type="text" value="{$row.parent_info_ids}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_identification')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_identification" class="form-control form-control" name="row[parent_identification]" type="text" value="{$row.parent_identification}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_birthday')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_birthday" class="form-control datetimepicker form-control" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[parent_birthday]" type="text" value="{$row.parent_birthday}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_age_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_age_number" class="form-control form-control" name="row[parent_age_number]" type="text" value="{$row.parent_age_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_age_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_age_unit" class="form-control form-control" name="row[parent_age_unit]" type="text" value="{$row.parent_age_unit}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_last_menstrual_period_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_last_menstrual_period_date" class="form-control form-control" name="row[parent_last_menstrual_period_date]" type="text" value="{$row.parent_last_menstrual_period_date}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_weight')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_weight" class="form-control form-control" name="row[parent_weight]" type="text" value="{$row.parent_weight}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_height')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_height" class="form-control form-control" name="row[parent_height]" type="text" value="{$row.parent_height}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_sex')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-parent_sex" class="form-control selectpicker" name="row[parent_sex]">
                {foreach name="parentSexList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.parent_sex"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
